The aim of this Contestable Policy Fund study is to develop new, innovative or adapted approaches that will improve the alignment of health and employment services for those with common mental health problems.
Our review of the evidence and consultations led to three main findings, which also form our recommendations to the Government:
• Earlier access to specialist services will improve the employment and wellbeing outcomes of people with common mental problems and employment needs.
• Co-location or integration of employment advice and mental health treatment is likely to improve outcomes.
• Given the limitations in the evidence base for improving employment
outcomes of people with common mental health problems the evidence base should be improved through for instance piloting and social experimentation.
We have proposed four policy options out of a longlist of over 30 options. The options were identified through a review of the evidence and consultations with stakeholders. Our shortlist is not exhaustive and other policy options could be considered. The options are also complementary and could potentially be used as a package of support.
In essence, our work identified four options that appear acceptable to stakeholders, feasible to implement, have grounding in the evidence, and give an increased likelihood of a successful outcome. The options also importantly call for structural change or increased integration in terms of how employment and health services are delivered (eg by offering access to specialist mental health and employment support in employment services or placing employment advice in primary care). Furthermore, the policy options aim to provide earlier access to specialist services than is the case now in many locations. Finally, each of these policy options could be piloted.
Our concluding thoughts pertain to the enablers of these policy options. As mentioned in Chapter 5, we identified two main enablers when drawing up the shortlist of four policy options.
More effective referrals to specialist services through a single assessment
The development of an assessment tool that measures claimant self-efficacy and wellbeing could potentially create a gateway to specialist help. This has also been proposed in the recent Disability and Health Employment Strategy (DWP, 2013). The formulation of a specialist tool that identifies mental health and employment needs could enable all four policy options to improve targeting and service provision. It
could also be used in other interventions and by other stakeholders such as Work Programme providers and third parties providing services for those with mental health problems.
Currently, there is no accepted way, nor ‘off the shelf’ instrument, to assess self-efficacy for work. In the current system clients undergo a range of assessments for particular problems and needs, but no assessment looks at employment needs and mental health in the round. Even if such an assessment were devised, challenges might be experienced in encouraging different services to adopt the tool and use it in the way intended. For instance, personal advisers in Jobcentre Plus locations only have a short amount of time with a benefit claimant and it may be difficult to perform an effective assessment. Rollout may require an incentive for service providers to use the tool (eg by setting minimum standards for public sector providers), guidance and training for staff and line managers. This may also need to be extended to a wider number of gatekeepers such as GPs who could more effectively refer individuals to specialist services and whose referrals may impact the success of a pilot. Clearly, a pilot of the four policy options would need to incorporate the design of the tool and determine the effectiveness of the tool in referring the appropriate individuals to specialist services. The DWP could build on the Employment and Wellbeing toolkit which was launched in January 2014 or the Work Programme employment advice toolkit (Working for Wellbeing) which is now widely used by Work Programme providers.
Incentivising service providers
Some form of joint commissioning may be needed to incentivise service providers to work across health and employment spheres. Those responsible for commissioning health services have not systematically focused on employment outcomes. Similarly, employment services commissioners have not focused explicitly on improving mental wellbeing. In the course of this study, we found examples of more integrated service delivery. Our consultations also revealed more willingness among health officials to engage with employment as a clinical outcome. A joint commissioning model may be part of piloting.
There are some risks in such joint commissioning. Integration of services may
become the objective itself rather than the outcome the integrated service is trying to achieve. A further risk is that in times of economic and fiscal constraints
commissioners often make savings in areas of joint funding rather than core areas.
As a result, funding set aside for joint commissioning may be vulnerable. In addition, a more scaled up service after the conclusion of the pilot underpinned by joint
commissioning may displace or disrupt initiatives that exist at local level and focus on integrated service delivery.
We have encountered some initiatives that brought together Jobcentres, local mental health services, IAPT and at times Work Programme providers. Some of these
initiatives may be quite effective on the basis of some anecdotal evidence that we collected as part of this study. Finally, it is unlikely that joint commissioning will be widely taken up without funding being made available by the departments involved
and clear expectations set in operational plans such as the NHS Mandate and NHS Outcomes Framework. For instance, in the health sector, the Government may emphasise the importance of employment outcomes Here, the DWP may have an advantage over DH in setting expectations for local Jobcentres due its relatively centralised delivery structure. DH will need to rely more on influencing and incentivising its local commissioners.
Designing robust pilots
Our work has focused mostly on proposing a number of policy options that appear promising in improving the employment outcomes of those with mental health
problems. The descriptions of the policy options in Chapter 5 provide suggestions for how the policy options could be piloted. A robust pilot design is essential because one of the aims of piloting is to improve the evidence base. We have proposed the use of RCTs, since pilots that randomly assign participants to treatment and control groups would be preferable in terms of generating robust evidence of effectiveness.
However, we note that there are challenges in implementing RCTs. If an RCT is not possible, those designing the pilots should attempt to build comparable treatment and control groups. This comparability should not just incorporate demographic factors but also motivations, relative wellbeing and job readiness. These are key aspects to consider in the facilitation of people with mental health problems gaining and sustaining employment. The pilot design would preferably also aim to
understand how the intervention can be scaled up and as such the intervention should be piloted in different geographies and contexts to draw out wider lessons for scaling up the intervention. In this way, it is hoped that the pilot will have a
demonstration effect for commissioners at all levels.
A case for investment
In Chapter 5, we have provided some conservative benefit-cost ratios for each policy option (except online). In each case, the benefits are likely to exceed the costs of the service, especially when taking into account wider benefits to individuals treated, society and the economy that this study could not make monetise. This study puts forward a case for investment by the Government. Our work has provided some strategic options for policymakers. However, this study has not set out in detail how the implementation and piloting would occur.
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